Therapists walk fine line in reporting violent plans

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Photos:Colorado massacre: Mourning the victims

Cynthia Davis, center, visits the roadside memorial set up for victims of the Colorado shooting massacre across the street from the Century 16 movie theater on Monday, July 30, 2012, in Aurora, Colorado. Twelve people were killed in the theater early July 20, 2012, during a screening of "The Dark Knight Rises." Suspect James Holmes was taken into custody shortly after the attack. More photos: Colorado movie theater shooting

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Photos:Colorado massacre: Mourning the victims

People visit the roadside memorial set up for victims of the massacre on Monday.

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Photos:Colorado massacre: Mourning the victims

Visitors pray around a cross at the memorial across the street from the theater on Saturday, July 28.

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Photos:Colorado massacre: Mourning the victims

Jeremy Blocker displays a new tattoo honoring the victims.

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Photos:Colorado massacre: Mourning the victims

Members of Alex Sullivan's family embrace at a memorial across the street from the Century 16 movie theater on Thursday, July 26.

A couple embraces as "Dark Knight Rises" star Christian Bale and his wife, Sandra Blazic, wait to place flowers at the memorial on Tuesday.

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Photos:Colorado massacre: Mourning the victims

Bale places flowers at the memorial while other mourners look on.

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Photos:Colorado massacre: Mourning the victims

Visitors pay tribute Tuesday, July 24, at the makeshift memorial.

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Photos:Colorado massacre: Mourning the victims

A cross stands at the makeshift memorial for victims across the street from the Century 16 theater on Tuesday.

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Photos:Colorado massacre: Mourning the victims

Greg Zanis of Aurora, Illinois, carries two of the 12 crosses he made for a makeshift memorial to the victims of last weekend's mass shooting at the Century 16 movie theater on Sunday, July 22.

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Photos:Colorado massacre: Mourning the victims

Greg Zanis writes the names of the victims of last weekend's mass shooting on the crosses before erecting them at the memorial across from the Century 16 movie theater on Sunday. Zanis, a carpenter, drove all night from Illinois to deliver the crosses.

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Parishioners pray during morning Mass, remembering victims of the theater shooting, at the Queen of Peace Catholic Church on Sunday.

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Angie Terry of Alabama prays next to a white wooden cross erected for victims.

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A man pauses before the crosses at the memorial near the Century 16 movie theater on Sunday.

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President Barack Obama embraces Colorado Gov. John Hickenlooper as Sen. Mark Udall, left, and Sen. Michael Bennet look on during a visit to the University of Colorado Hospital on Sunday.

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Mourners bow their heads in prayer during the vigil for the victims of the Aurora shooting.

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A woman is overcome with emotion during the vigil.

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Tiffany Garcia, right, and her 6-year-old daughter, Angelina Garcia, cry on Saturday, July 21, as they look at a memorial for the victims of Friday's shooting.

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Photos:Colorado massacre: Mourning the victims

People pray at a cross erected at the makeshift memorial across the street from the Century 16 theater on Saturday.

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Photos:Colorado massacre: Mourning the victims

Family, friends and former classmates of movie theater shooting victim A.J. Boik gather for a memorial service at Gateway High School on Saturday.

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Photos:Colorado massacre: Mourning the victims

Boik and his girlfriend were at the midnight showing of 'The Dark Knight Rises' when a gunman killed Boik and 11 other people.

Eman Alexander, 17, pins a ribbon on his shirt while joining family, friends and former classmates to honor shooting victim A.J. Boik.

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Photos:Colorado massacre: Mourning the victims

Denise Toepel of Denver sheds tears while visiting a makeshift memorial across the street from the Century 16 movie theater on Saturday, July 21.

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Handwritten signs decorate the makeshift memorial across from the Century 16 movie theater on Saturday.

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Photos:Colorado massacre: Mourning the victims

Gerald Wright, 24, relights candles that have blown out at the victims' memorial across from the movie theater.

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Photos:Colorado massacre: Mourning the victims

Aviation Boatswain's Mate 3rd Class Jajuan Mangual lowers the American flag on the flight deck of the aircraft carrier USS George H.W. Bush to half-mast on Saturday. One U.S. Navy sailor was killed in the shooting and another injured.

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Photos:Colorado massacre: Mourning the victims

Two women mourn near the theater on Saturday.

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Photos:Colorado massacre: Mourning the victims

Alicia Prevette, left, and Paul Stepherson attend a vigil for the victims Friday at the Century 16 movie theater.

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Photos:Colorado massacre: Mourning the victims

A woman lights a candle at a makeshift memorial where the victims of the massacre are mourned.

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Photos:Colorado massacre: Mourning the victims

Mourners hold hands at a vigil near the theater.

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Mourners hug as they grieve the loss of the victims.

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A group of teenagers stand behind a sign that reads "Strength."

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Dara Anderson, left, and Monique Anderson cry during a candlelight vigil across the street from the crime scene.

Confidentiality is paramount between a patient and a therapist, but it's not ironclad -- confession to a crime, or the possibility of a potential crime, is not supposed to remain a secret.

"There is no clear-cut rule that psychiatrists are ever taught, but frankly, the bar is set very low in terms of breaking confidentiality," says Xavier Amador, a clinical psychologist and adjunct professor of psychology at Columbia University's Teachers College. "If there is any certain specific threat made, you have an obligation to report it."

Lynne Fenton, a psychiatrist treating accused Colorado movie theater gunman James Holmes, 24, was so concerned about his behavior that she contacted several members of the University of Colorado's Behavior Evaluation and Threat Assessment team, known as BETA, which is responsible for evaluating potential threats, CNN affiliate KMGH reported Wednesday.

"Fenton made initial phone calls about engaging the BETA team" in "the first 10 days" of June but it "never came together" because in the period Fenton was having conversations with team members, Holmes began the process of dropping out of school, a source told KMGH.

Sources told KMGH that when Holmes withdrew from school, the team "had no control over him."

But Gene Deisinger, deputy chief of police at Virginia Tech and head of the school's threat assessment team, says, "We don't close a case solely due to someone leaving the university."

"The decision to close a case is made based on assessment that the person no longer poses a threat of violence or significant disruption to the campus or to any other identifiable target," he says.

Dr. Lynne Fenton reportedly saw Holmes as a patient.

Photos:Colorado movie theater massacre

Photos:Colorado movie theater massacre

The public gets its first glimpse of James Holmes, then 24, the suspect in the Colorado theater shooting during his initial court appearance July 23, 2012. With his hair dyed reddish-orange, Holmes, here with public defender Tamara Brady, showed little emotion. He is accused of opening fire in a movie theater July 20, 2012, in Aurora, Colorado, killing 12 people and wounding 70. Holmes faces 166 counts, almost all alleging murder or attempted murder. He has pleaded not guilty by reason of insanity. More photos: Mourning the victims of the Colorado theater massacre

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Photos:Colorado movie theater massacre

Police release the official photo from Holmes' booking after the shooting.

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Holmes often had a blank stare during his July 23, 2012, court appearance, seeming to be in a daze.

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Photos:Colorado movie theater massacre

Victims and their relatives and journalists watch the proceedings in 2012.

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Flags fly at half-staff on July 23, 2012, at the Arapahoe County Courthouse in Centennial, Colorado, where the movie theater shooting suspect had his first court appearance. The murder counts against Holmes carry a possible death penalty.

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Photos:Colorado movie theater massacre

Arapahoe County District Attorney Carol Chambers talks to reporters July 23, 2012, before heading into the courthouse. The murder counts against Holmes carry a possible death penalty.

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Photos:Colorado movie theater massacre

Family members of the victims arrive at the courthouse July 23, 2012, for the suspect's first court appearance.

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Photos:Colorado movie theater massacre

The Century Aurora 16 multiplex in Aurora becomes a place of horror after a gunman opened fire July 20, 2012, in a crowded theater.

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Photos:Colorado movie theater massacre

Holmes is accused of opening fire during a midnight screening of the Batman movie "The Dark Knight Rises." Holmes purchased four weapons and more than 6,000 rounds of ammunition, police say.

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Photos:Colorado movie theater massacre

Police investigate outside the Century 16 multiplex July 21, 2012, a day after the mass shooting.

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Agents search the suspect's car outside the theater.

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Aurora police escort a sand-filled dump truck containing improvised explosive devices removed from Holmes' booby-trapped apartment on July 21, 2012. Authorities have said they believe the suspect rigged his place before leaving for the movie theater.

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Photos:Colorado movie theater massacre

Police break a window at the suspect's apartment July 20, 2012, in Aurora.

A Federal ATF officer carries protective gear onsite at the home of the shooting suspect.

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President Obama speaks on the shootings at a July 20, 2012, event in Fort Myers, Florida.

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Moviegoers are interviewed at the Century Aurora 16.

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Officers gather at the theater July 20, 2012.

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Investigators were a common sight at the theater on July 20, 2012.

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Photos:Colorado movie theater massacre

Authorities gather at the shooting suspect's apartment building in Aurora. Police broke a second-floor window to look for explosives the suspect claimed were in the apartment.

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Screaming, panicked moviegoers scrambled to escape from the black-clad gunman, who wore a gas mask and randomly shot as he walked up the theater's steps, witnesses said.

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Onlookers gather outside the Century Aurora 16 theater.

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A woman sits on top of her car near the crime scene.

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Police block access to the Town Center mall after the shooting.

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Cell phone video taken by someone at the theater showed scores of people screaming and fleeing the building. Some, like this man, had blood on their clothes.

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Witnesses told KUSA the gunman kicked in an emergency exit door and threw a smoke bomb into the darkened theater before opening fire.

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What is believed to be the suspect's car is examined after the shooting.

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Photos:Carpenter comforts shooting victims with crosses

Photos:Carpenter comforts shooting victims with crosses

Crosses comfort victims – Greg Zanis places crosses at a makeshift memorial to victims of the Aurora, Colorado, movie theater shooting on Sunday, July 22. Zanis says he began building crosses to help comfort others after first creating one for himself as a memorial to his late father-in-law.

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Photos:Carpenter comforts shooting victims with crosses

Crosses comfort victims – Zanis prays with Aurora Mayor Steve Hogan at the site of 12 crosses to remember those killed in the movie theater massacre.

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Crosses comfort victims – Zanis says he has created more than 13,000 crosses for people across the country. Here, he puts the names of victims of a hotel shooting on crosses in Brookfield, Wisconsin, in 2005.

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Photos:Carpenter comforts shooting victims with crosses

Crosses comfort victims – Zanis also built crosses for the victims of the 1999 Columbine school shooting.

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Photos:Carpenter comforts shooting victims with crosses

Crosses comfort victims – "I am doing it for the victims, but this is a public grieving. This allows the public a place to go to and have that big cry." says Zanis, an electrician and former carpenter.

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Photos:Carpenter comforts shooting victims with crosses

Crosses comfort victims – Zanis says he looks for a chance to talk and pray with families when he builds the crosses. "I share my loss and that just opens them up to sharing their loss," he says. "This is a perfect thing for me to do."

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Photos:Christian Bale visits Aurora

Photos:Christian Bale visits Aurora

Christian Bale visits Aurora – Actor Christian Bale and his wife, Sandra Blazic, visit the makeshift memorial for victims of the Aurora, Colorado, shooting across the street from the Century 16 movie theater on Tuesday, July 24.

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Photos:Christian Bale visits Aurora

Christian Bale pays tribue in Aurora – Bale plays the lead role of Batman in "The Dark Knight Rises," the film that was playing when suspected gunman James Holmes opened fire in the theater.

Christian Bale pays tribue in Aurora – A couple at the memorial site embraces in front of Bale and his wife.

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Christian Bale pays tribue in Aurora – Bale and Blazic appeared somber and shied away from any media attention.

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Christian Bale pays tribue in Aurora – Bale and Blazic are surrounded by other visitors at the memorial on Tuesday.

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However, Deisinger, a former clinical psychologist, added that without knowing more details, it's impossible to draw conclusions about the University of Colorado's actions.

There remains a gray area for clinicians when it comes to flagging concerns about a patient. Simply put, it comes down to a therapist's interpretation about how specific a patient is when talking about violent thoughts or plans.

A specific threat means the patient clearly identified a targeted person or group, or gave specific details like a location or a time frame.

"If you have a patient who says, 'I'm planning to kill my parents,' that's the far end of the spectrum and would trigger a warning to the parents," says Alta Charo, medical ethicist and legal professor at University of Wisconsin.

A nonspecific threat would be a patient venting that he or she is angry and feels like he or she could kill somebody, according to Charo.

In this gray area, a clinician's professional judgment is key. They have to identify whether there is a sense of urgency, and if there is a likelihood of a patient acting on the thoughts. A patient's history of violence, mental illness and substance abuse is also considered, according to the Journal of Family Practice.

Two California Supreme Court rulings, called Tarasoff I and II, shaped the ground rules for a clinician's duty to warn and protect a patient from themselves, and/or a potential victim or crime from taking place.

The Tarasoff case arose when Prosenjit Poddar, a student at the University of California, Berkeley, told his therapist of his intention to kill fellow student, Tatiana Tarasoff.

The therapist informed campus police, who briefly detained the student, but released him after he appeared rational and promised to stay away from Tarasoff. No further action was taken, and Tarasoff was not warned of the potential threat. Two months later, in October 1969, Poddar stabbed and killed Tarasoff.

The decision in Tarasoff I says therapists have a duty to warn a potential victim of a threat, even if it violates doctor-patient confidentiality. Tarasoff II, an extension of the first ruling, says the therapist also has an obligation to protect the person by alerting the appropriate law enforcement agency.

At Virginia Tech, with more than 30,000 students, faculty and staff, the core group of the Threat Assessment Team is comprised of nine individuals from different parts of the university, including school police, academic officials and representatives from counseling services.

In a typical year, Deisinger says, his group responds to "350 to 400" reports of troubling behavior. In most cases, he says, a simple investigation finds no danger.

A federal law known as the Clery Act requires schools to report to law enforcement any criminal acts on campus, and to report any immediate threats to health or safety.

But disturbing behavior often doesn't reach that threshold, according to Steven Healy, the former director of public safety at Princeton University who helped develop a widely used threat assessment program, using a grant from the Department of Justice.

"The majority of the cases reported are just unusual communication or odd behavior that doesn't break the law," says Healy. "We aim for early intervention with a simple conversation to assess the threat, or to push the person towards mental health services."

The bar is higher for psychologists, psychiatrists and other medical professionals to report to police. Failing to identify potential harm by a clinician would not be a criminal offense, according to Amador, but it can open a door for a civil lawsuit if they did not disclose the information.

All states require therapists to inform patients before a session that their confidentiality agreement may be revoked if it is determined the patient is a threat to themselves or others. But details vary from state to state on who the therapist is required to inform.

In Colorado, doctors, nurses, mental health professionals and their staffs are required to break confidentiality and warn a potential victim and alert law enforcement if a serious threat is suspected.